Project Summary The population of chronic hemodialysis (CHD) is rapidly growing. Rates of infections caused by antimicrobial-resistant bacteria (ARB) are among the highest in this patient population. Antimicrobial use is the main risk factor for the emergence and spread of ARB. There is a paucity of data quantifying antimicrobial use and inappropriate prescribing patterns among CHD patients, a priority population for the Agency of Healthcare Research and Quality. Comprehensive antimicrobial stewardship programs, specifically targeting this population in out-patient dialysis units, have not been developed. We initiated a pilot study in two out-patient dialysis units to quantify and characterize inappropriate prescribing of antimicrobials. Our preliminary data demonstrated that 27.5% of antimicrobial doses were prescribed inappropriately, as per national guidelines. Third/fourth generation cephalosporins, followed by vancomycin, were the most common antimicrobials prescribed inappropriately. The three key categories of inappropriate prescribing were a] national consensus criteria for diagnosing an infection were not met, b] lack of de-escalation of antimicrobial therapy and c] surgical prophylaxis for hemodialysis access-related procedures were continued e24 hours post-procedure. In this proposal we will develop, implement and demonstrate the effectiveness of an antimicrobial stewardship program in reducing antimicrobial prescribing and inappropriate prescribing in out-patient dialysis units. This program will include an educational intervention and both system and social/behavioral change strategies. The latter will involve the implementation of the Positive Deviance approach. An interrupted time series design will be used with monthly data collection during the12-month pre-intervention period and the 12- month post-intervention period. The specific aims of this proposal are: Aim 1-To demonstrate the effectiveness of an antimicrobial stewardship program in reducing antimicrobial use in out-patient hemodialysis units. Aim 2- To demonstrate the effectiveness of an antimicrobial stewardship program in reducing inappropriate antimicrobial use in out-patient hemodialysis units. Aim 3- To demonstrate the cost-effectiveness of this antimicrobial stewardship program. Demonstrating the efficacy of this antimicrobial stewardship program will provide an unmet and long overdue need in the CHD population and will ultimately improve health outcomes in this patient population by reducing the prevalence of ARB and ARB infections.